EPA: Benign Anorectal Disease (Fistula)

EPA: Benign Anorectal Disease (Fistula)

Evaluatee Name (Last, First)*

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Evaluator Name (Last, First)*

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Date of Assessment*

Rotation*

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Phase of Care*

UPDATE! You can only select one phase of care. Complete an assessment for each phase of case separately.

Intraoperative

Postoperative

Preoperative/Nonoperative

For each category, select the statement that best describes the resident behavior for this patient encounter.

Preoperative: Evaluation*

OBTAINS H&P INCLUSIVE OF ANORECTAL EXAM with cultural humility; develops an INCOMPLETE DIFFERENTIAL for anal pain or bleeding

Evaluates anal pain or bleeding & ORDERS DIAGNOSTIC TESTS AS INDICATED. NEEDS ASSISTANCE to differentiate between patients best served by office or OR procedures.

ASSESSES BASELINE BOWEL CONTINENCE but does not discover symptoms such as urgency, incontinence to flatus, and fecal smearing. DEMONSTRATES KNOWLEDGE OF LIMITATIONS OF IN-OFFICE PROCEDURES and identifies a patient who may be a candidate.

SYNTHESIZES ALL RELEVANT DATA & generates PERSONALIZED TX PLAN, including managing anticoag, portal HTN, and other relevant considerations. Assess baseline bowel continence, recognizing its influence on the treatment plan.

Not applicable/not observed

Preoperative: Communication with Patient*

Shows cultural humility & respect for privacy when discussing sensitive topics & exam findings. Discusses rationale for anoscopy. EXPLAINS STEPS OF CARE PLAN BUT NOT EXPECTED POSTOP COURSE/RECOVERY TIMES; reports some potential harms/benefits of operation

BROADLY DESCRIBES EXPECTED OUTCOMES OF NONOP MANAGEMENT BUT OMITS DETAILS such as the likelihood of treatment success or steps for escalation of therapy

DISCUSSES ANOSCOPY FINDINGS/PATHOLOGY; explains nonop management of pathology & some surgical options. OBTAINS INFORMED CONSENT FOR STRAIGHTFORWARD PROCEDURE/ANSWERS BASIC QUESTIONS. Discusses alternatives/risks/benefits of recommended surgical options.

Explains the process of the exam with calming reassurance. PERSONALIZES THE DISCUSSION to patient's language preference and social considerations, using a variety of methods to ensure understanding. DISCUSSES POSTOP CARE AND EXPECTATIONS.

Not applicable/not observed

Preoperative: Medical Knowledge*

Demonstrates knowledge of BASIC PATHOPHYSIOLOGY of anorectal disease.

STATES THE STEPS OF ANOSCOPY, including need for chaperone, but CANNOT PERFORM PROCEDURE INDEPENDENTLY. Manages common anorectal condition nonoperatively and recognizes the importance of bowel habit optimization.

Develops step-wise plan for HEALTHY PT W/ ANORECTAL CONDITION (fiber & healthy toileting habits). Knows tx options: Fissure (topical Ca channel blockers, topical vasodilators) Fistula (EUA) Hemorrhoid (nonop, banding, excision) Condyloma (excision/fulg)

COMPREHENSIVE KNOWLEDGE OF TX OPTIONS: Anal fissure (Botox, sphincterotomy) Fistula (fistulotomy, seton, or specialty referral) Condyloma (topical tx). Uses respirator/closed circuit smoke evacuation to minimize exposure to aerosolized HPV when indicated.

Not applicable/not observed

Preoperative: Anal exam*

IDENTIFIES NORMAL ANAL ANATOMY and obvious exam findings such as a mass or decreased sphincter tone but DOES NOT IDENTIFY SUBTLE FINDINGS

RECOGNIZES PERIANAL LESIONS ON EXTERNAL EXAM but NOT ABLE TO DIAGNOSE THEM (eg, condyloma vs skin tag). Performs internal & external anal exam but may OMIT ASSESSMENT OF REFLEXES, TONE, AND FUNCTION.

IDENTIFIES ABNL SPHINCTER ANATOMY OR FISSURE/FISTULA on exam. PERFORMS ANOSCOPY w/ cultural humility & chaperon present but NEEDS ASSISTANCE; displays TECHNIQUE THAT IS LESS GENTLE than ideal (does not provide pt w/ verbal narrative, causing discomfort.

PERFORMS A THOROUGH ANAL EXAM, including external exam, assessing reflexes/tone/function; PERFORMS ANOSCOPY w/ cultural humility & chaperon present using GENTLE AND THOROUGH TECHNIQUE. Recognizes normal and abnormal pathology on exam.

Not applicable/not observed

Case Difficulty*

Straightforward

Moderate

Complex

Intraoperative: Steps of Operation*

States overall goals of the operation but UNABLE TO OUTLINE SPECIFIC STEPS. Identifies some options for pt positioning for anorectal procedure but demonstrates INCOMPLETE UNDERSTANDING OF POTENTIAL FOR NERVE/PRESSURE INJURY.

Provides BASIC DESCRIPTION OF OPERATIVE PLAN, OMITTING SOME STEPS. Determines OPERATIVE POSITIONING (EG, PRONE FOR ANTERIOR LESIONS, LITHOTOMY FOR POSTERIOR LESIONS). Recognizes importance of protecting against nerve/pressure injuries.

OUTLINES STEPS OF STRAIGHTFORWARD CASE. Has knowledge of typical instruments in most anorectal surg; suggests position for procedure & identifies other options; describes potential for nerve injury & correctly identifies nerves at risk for each position.

MODIFIES THE OPERATIVE PLAN WHEN THE PATIENT'S DISEASE OR ANATOMY DOES NOT ALIGN WITH WHAT WAS ANTICIPATED. Modifies instrument selection and tissue handling based on intraop findings.

Intraoperative: Technical Skills (Fistula)

NEEDS ASSISTANCE to recognize dissection planes & to proceed after each step. Handles instruments INEFFICIENTLY w/ limited dexterity & frequent repositioning; incompletely understands tissue handling; WITH DIRECTION, CAN SUTURE/TIE KNOTS CORRECTLY.

Describes use of some instruments in anorectal procedures. MAINTAINS DISSECTION PLANE IF IDENTIFIED BUT CANNOT INDEPENDENTLY ENTER IT; FREQ DEVIATES FROM CORRECT PLANE. Sometimes REQUIRES GUIDANCE TO MOVE TO NEXT STEP. Controls bleeding with direction.

CAREFUL TISSUE HANDLING & IDENTIFIES CORRECT PLANE but cannot self-correct; anticipates next step correctly in straightforward case. WITH SUPERVISION, IDENTIFIES SPHINCTER MUSCLE ANATOMY relative to the tract but UNSURE OF WHICH OPERATION to perform.

INDEPENDENTLY PERFORMS OPERATION. Attempts control of bleeding by packing/cautery/suture ligation. IDENTIFIES ANATOMY of the sphincter muscles relative to the tract and MODIFIES OPERATIVE PLAN to include a fistulotomy or seton as appropriate

Postoperative: Patient Care*

CARRIES OUT POSTOP PLAN initiated by more experienced health care provider. Identifies SIMPLE POSTOP PROBLEMS such as pain and bleeding

MANAGES ROUTINE POSTOP CARE, recognizes common postop complications, & evaluates/manages SIMPLE PROBLEMS.

RECOGNIZES SEVERE POSTOP PROBLEM (PELVIC SEPSIS) BUT REQ ASSISTANCE TO MANAGE; selects APPROPRIATE METHOD OF POSTOP FOLLOW-UP w/ consideration of case complexity, health care system cost, & patient resources (eg, telehealth).

MANAGES COMMON/SIGNIFICANT POSTOP COMPLICATIONS, including urinary retention, escalating pain, infxn, incontinence, recurrence, & bleeding. CUSTOMIZES MULTIMODAL, OPIOID-SPARING PAIN MANAGEMENT (evidence-based guidelines) & discusses opioid plan w/ pt

Not applicable/not observed

Postoperative: Communication with Patient*

Provides updates and ANSWERS TO STRAIGHTFORWARD QUESTIONS from a patient/caregiver(s) and other health care team members in a respectful and understandable way

Discusses intraop findings & postop course for STRAIGHTFORWARD PROCEDURE but cannot answer questions beyond descriptions or recognize sx/signs of postop problems; articulates info to other health care team members but does not develop plan independently

Discusses intraop findings/postop course but DOES NOT USE STRAIGHTFORWARD LANG NOR CONFIRM UNDERSTANDING. Tells how to report worsening sx but doesn’t give specific warning signs. CONSIDERS PT BARRIERS/DISPARITIES when devising/communicating postop plan

ENSURES UNDERSTANDING/EMPLOYS CULTURAL HUMILITY/USES STRAIGHTFORWARD LANG regarding findings & intraop course. Shares postop comp in caring/respectful manner. Recognizes importance of communication to mitigate comp; outlines process to report worrisome sx

Not applicable/not observed

Overall Performance*

Based on your observation, what level of autonomy would you trust the resident to perform this task at the NEXT encounter?

Limited Participation: Learner has basic knowledge and skills, attending does show and tell

Direct Supervision: Attending provides active help

Indirect Supervision: Attending provides passive help

Practice Ready: Attending is available but is not needed for routine cases/presentations, but input may be needed for complex cases

Comment*

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